STEPHAN MOSTOWY BSc, MD, FRCS (C) Endovascular/Vascular Surgeon Kelowna General Hospital

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1 STEPHAN MOSTOWY BSc, MD, FRCS (C) Endovascular/Vascular Surgeon Kelowna General Hospital

2 Faculty/Presenter Disclosure Faculty: Dr. Stephan Mostowy Relationships with financial sponsors: NONE

3 From head to gangrenous toes.

4 VASCULAR SURGEONS BLOOD FLOW DELIVERY BUSINESS CAROTID DISEASE pipe cleaning AAA blood safety redirection TRAUMA stop the bleeding PERIPHERAL VASCULAR DISEASE blood supply redistribution

5 OBJECTIVES To develop an approach to peripheral vascular disease and woundsmedical risk factor management, work up and referral to a Vascular Surgeon To ensure appropriate communication when transferring a critical life or limb patient and ensure optimal treatment at base hospital before patient leaves to a vascular centre To understand the treatment options for limb salvage- the endovascular evolution, bypass, and the importance of amputation To improve understanding of post operative care and ensuring success in wound healing and limb salvage Review approach and treatment to the swollen limb To review venous disease management- classification of venous disease, venous ulcers, treatment options for varicose veins, and DVT

6 PRESENTATION OF PVD Symptomatic 10% Intermittent claudication Critical Limb Ischaemia -Pain at rest - Tissue loss -Gangrene Asymptomatic 90%

7 ANKLE BRACHIAL PRESSURE INDEX NORMAL > 1.0 ABNORMAL < 0.9 CLAUDICATION CRITICAL < 0.5 Watch for DM pts higher readings due to vessel calcification

8 NATURAL HX OF PVD PTS Annual risk : - Mortality 6.8% - MI 2.0% - Intervention 1.0% - Amputation 0.4% Ouriel K, Lancet 2001; 358:

9 FATE OF PAD PTS PRESENTING WITH CLAUDICATUION Gupta A, et al. Can J Cardiol 2005;21(12):

10 BEST MEDICAL THERAPY Risk factor modification -Smoking cessation -Diet, Exercise -Treatment of diabetes -Antihypertensive therapy Statins Antiplatelet therapy Peri-operative Beta blockade ASPIRIN STATIN ACE-I The Magic Pill

11 ACURE LIMB ISCHAEMIA What are the 6 P s of Diagnosis? P allor P ulseless P ain P araesthesia P aralysis P erishing Cold NORMAL PULSES ON THE OTHER LEG

12 CRITICAL ACUTE ISCHEMIA Threatened Leg Partial weakness Partial sensory loss Intact but slow capillary refill Arterial doppler signal absent Venous signal present

13 MANAGEMENT General Measures 5000 iu heparin IV STAT -Prevent propagation of proximal and distal thrombus -Decrease risk of associated venous thrombosis Pressure care Bed position-leg down Do not heat or cool limb IV Fluids Analgesia Oxygen Therapy Lab work (Blood): Renal profile, Coagulation, CBC Diagnostics: CXR, ECG

14 CHRONIC LIMB ISCHAEMIA -Prev. HX Months/years of claudication -Prev. HX of bypass -Night/Rest pain -Dependent rubour / Pale elevation -Tissue loss/gangrene ABNORMAL PULSES ON ASYMPTOMATIC OTHER LEG

15 SUBCRITICAL ACUTE ISCHAEMIA Viable Leg Normal movement Normal Sensation Capillary refill intact Audible arterial doppler signal

16 Profound paralysis Tense muscles No sensation Absent capillary return Fixed skin staining Guttering of veins No Arterial Or Venous doppler signal ACUTE ISCHAEMIA Irreversible

17 Acutely Ischemic Limb Irreversible fixed skin staining tense muscles Severe white leg paralysis Moderate dusky leg mild anesthesia Amputation or Palliative Care Surgery Angiography CTA

18 Esp with ENDOVASCULAR TECHNIQUES

19 PATHWAY FOR ISCHAEMIC ULCER OR OSTEOMYELITIS The picture can't be displayed. The picture can't be displayed. REVASCULARIZE DEBRIDE/AMPUTATE GOAL TO HEAL The picture can't be displayed. The picture can't be displayed. The picture can't be displayed.

20 PVD- POST OP BYPASS CARE The picture can't be displayed. Wound issues - incisions and ulcers Perfusion- refill or pulses Graft pulse palpable- vein not gortex

21 Wounds/ulcers PVD POST OP ISSUES Concerns with graft or patch underneath Aggressive Abx Pulsatile groins- false aneurysms Do not drain the pulsatile abscess

22 NO LOCAL IN ISCHAEMIC FEET! Will result in local necrosis and non healing risk of limb loss Assess vasculature before any minor procedure on feet

23 PRESSURE- DM PTS

24 PRESSURE WATCH OTHER LEG

25

26 BLUE TOE SYNDROME -ASA/Plavix/Statin -Find Source of Embolus -Treat to ensure Healing

27 AMPUTATIONS PART OF TREATMENT AND NOT A FAILURE

28 TRANSMETATARSAL AMPUTATION

29 BELOW KNEE AMPUTATION PRESERVE THE KNEE JOINT

30

31 VASCULAR KGH TEAM THAT HELPS THE PATIENTS Nurse Clinicians ET Nurses Our ward Nurses PT/OT/Rehab/Prosthetist Vascular Surgeon

32 PT & FAMILY JOURNEY TO HEAL

33 The SWOLLEN LEG Depends on the hx and px ACUTE vs CHRONIC What is the DDx? DVT- ACUTE Cellulitis Deep venous insufficiency Chronic ischaemia lymphedema

34 WHEN IS ELEVATION OF LEG CRUCIAL? Cellulitis Reperfusion edema Lymphaedema Post-Op lymph leak Deep venous insufficiency DVT Venous ulcer

35 SWELLING

36 SWELLING AND ULCER

37 COBAN/COBAN LITE WRAPS

38 WHEN DOES ONE NOT ELEVATE? Acute ischemic limb Acute on chronic ischemic limb Arterial ulcer

39 DIFFERENCES BETWEEN ARTERIAL VS VENOUS ULCERS? ARTERIAL PUNCHED OUT PALE, DRY COOL LIMB/FOOT PAINFUL WITH ELEVATION VENOUS SHALLOW, MOIST GAITER AREA EDEMA VARICOSE VEINS LIPODERMATOSCLEROSIS PAINFUL WITH DEPENDENCY

40 Can compression therapy be used in the patient with edema and cellulitis? YES Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, 2012

41 EDEMA & COMPRESSION THERAPY IN CELLULITIS 1. Normal anti-streptococcal properties of skin are inactivated by edema fluid 2. Compression therapy: Removes protein-containing fluid from the subcutaneous tissues Increases blood flow to tissues Increases antibiotic concentration in tissues

42 CELLULITIS OF LEG Healed after 10 days of antibiotics and 5 weeks of compression therapy

43 VENOUS DISEASE

44 Leo - 56 male Leg aches esp end of day Number of years Prev injections- recurred Stockings help + FHx varicose veins No DVT No # Normal distal pulses Venous Duplex- GSV reflux; normal deep system

45 WHAT IS THE PROBLEM? Saphenous Incompetence

46 SAPHENOUS INCOMPETENCE What are the treatment options? Conservative Surgical Stripping High ligation & distal foam sclerotherapy Thermal Ablation Radiofrequency Laser Foam Sclerotherapy VenaSeal

47 CONSERVATIVE Compression stockings worn regularly prevents long term adverse outcomes swelling ulceration phlebitis Small spider/reticular veins sclerotherapy

48 TREATMENT FOR THROMBOPHLEBITIS Not an infection NSAIDS Elevate Compression Compress Takes 6-8 weeks

49 DVT Anticoagulation Mechanical -Elevate -Compression stocking -prevent post phlebitic limb NO NEED FOR SERIAL U/S

50 COMPRESSION THERARY & ACUTE DEEP VENOUS THROMBOPHLEBITIS Increases venous flow Prevents further clotting Occludes superficial veins that could clot Does not cause an increase in pulmonary embolism Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA (September), p 18 Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4 th Edition, Ed. BB Bates-Jensen, 2012

51 WHAT IS THE POST PHLEBITIC LIMB? -Chronic but preventable condition that leads to -limb pain -swelling -skin discolouration -rash -Seen at 10yrs f/u in 56% of DVT s

52 BRENDA - 63 FEMALE DIABETES POORLY CONTROLLED Severe diabetic foot infection Fevers despite IV ABx Purulent drainage Pain in plantar space Perfusion to foot adequate NEEDS OPERATIVE DRAINAGE AND DEBRIDEMENT

53 PATIENT EDUCATION What are the Do s? Wash feet daily, dry well, inspect Check hidden areas carefully Anti-fungal powder Careful nail hygiene Early treatment of wounds Wear comfortable, well fitted shoes Natural fibre socks are best

54 PATIENT EDUCATION What are the Don ts? Walk barefoot EVER Wear new shoes without breaking in Leave wounds untreated Burn their feet Cut nails too short Ignore discomfort SOAKING

55 INDICATIONS FOR REFERRAL Callus formation Ulceration Ischaemic change Acute local sepsis NEED TO DRAIN PUS DEBRIDE NECROTIC TISSUE Non-healing trauma

56 Hope this session has helped in what to do with vascular patients

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